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Flashcards in ENDOCRINE Deck (81):
1

The most important prognostic factors in survival of patients with differentiated thyroid cancer are

AGE,
grade,
extracapsular extension,
distant metastasis,
and size of the tumor.

2

basic criterion to be low risk papillary thryoid cancer and what is treatment



Partial thyroidectomy can be performed for patients with thyroid cancer that is <45 and no extracapsular invasion. However, there is some data to support doing a total thyroidectomy in this patient population, but it is not the standard of care.

3

Differentiated thyroid cancers The staging is as follows:


Papillary or follicular (differentiated) thyroid cancer in patients younger than 45:

Stage I: ANY T, any N, M0

Stage II: any T, any N, POSITIVE METS!

Papillary or follicular (differentiated) thyroid cancer in patients 45 years and OLDER:

Stage I: T1, N0, M0:
The tumor is 2 cm or less across and has not grown outside the thyroid.

Stage II: T2, N0, M0::
The tumor 2-4 cm across and has not grown outside the thyroid (T2).

Stage III: One of the following applies: T3, N0, M0: T3 LARGER THAN 4 cm across or has grown slightly outside the thyroid (T3),
not spread to nearby lymph nodes (N0) or distant sites (M0).

T1 to T3, N1a, M0: The tumor is any size and may have grown slightly outside the thyroid (T1 to T3). It has spread to lymph nodes around the thyroid in the neck (N1a) but not to other lymph nodes or to distant sites (M0). Stage IVA: One of the following applies:

T4a, any N, M0: The tumor is any size and has grown beyond the thyroid gland and into nearby tissues of the neck (T4a). It might or might not have spread to nearby lymph nodes (any N). It has not spread to distant sites (M0). T1 to T3, N1b, M0: The tumor is any size and might have grown slightly outside
the thyroid gland (T1 to T3). It has spread to certain lymph nodes in the neck (cervical nodes) or to lymph nodes in the upper chest (superior mediastinal nodes) or behind the throat (retropharyngeal nodes) (N1b), but it has not spread to distant sites (M0).
Stage IVB (T4b, any N, M0): The tumor is any size and has grown either back toward the spine or into nearby large blood vessels (T4b). It might or might not have spread to nearby lymph nodes (any N), but it has not spread to distant sites (M0).
Stage IVC (any T, any N, M1): The tumor is any size and might or might not have grown outside the thyroid (any T). It might or might not have spread to nearby lymph nodes (any N). It has spread to distant sites (M1).
Answer A: This is not a recognized stage in the TNM staging system

4

Primary hyperaldosteronism

is also known as Conn syndrome.

The most common presentation of primary hyperaldosteronism is difficult to control hypertension.

Hypertension results from unopposed aldosterone secretion which acts on the kidneys to absorb sodium and increases intravascular volume.

HYPOK and ALKalosis from:
Sodium is for potassium and hydrogen ions in the kidney which further increases sodium retention in the setting of hyperaldosteronism at the expense of decreased potassium and hydrogen ions in the serum.

Other symptoms of hyperaldosteronism are non-specific including weakness, fatigue and headaches. The net effect is hypertension, hypokalemia and alkalosis. (Sodium is retained at the expense of potassium and hydrogen ions).
Bottom Line: Hyperaldosteronism is associated with hypertension, hypokalemia and alkalosis.

5

Operative treatment of acute PID

Operations are restricted! to:

life-threatening infections,
ruptured tuboovarian abscesses,

6

Weak easy fatigue of voice after thyroid injury
what nerve
what does it innervate
where is it - land marks

EXTERNAL branch of the superior laryngeal nerve

innervation to the CRICOTHYROID muscle, which tilts the LARYNX during speaking to affect pitch

crosses the superior thyroid vessels
more than 1 cm above the level of the superior thyroid pole

7

stimulate the release of gastrin

Amino acids
Alkaline environment
Gastric distension
Calcium
vagal input

8

official rule on intraoperative time frame of PTH levels

(3-5) minute half life of parathyroid hormone (PTH).

Within 10 minutes of gland excision, a drop of at least 50% of the highest pre-EXCISION of GLAND (CAREFUL - NOT pre skin incision) value indicates complete resection of hyperfunctioning glands (choices B and C).

Failure to drop after 10 minutes does not imply the removed gland was normal (choice A). It only confirms there is remaining hyperfunctioning tissue within the body.

Even after a successful parathyroidectomy, if there are remaining glands, the patient is still at risk of developing a recurrence of hyperparathyroidism in the future (choice D).

Bottom Line: A 50% drop in parathyroid hormone (PTH) value after gland excision, as compared to the highest value either before skin incision or just before gland excision, is needed to confirm removal of all hyperfunctioning gland.

9

Familial Hypercalcemic Hypocalciuria



autosomal dominant disease caused by

increased calcium resorption in the kidney due to a defective PTH receptor.

(kidney is just absorbing extra calcium)

mild hypercalcemia

normal levels of parathyroid hormone.

DO NOT TREAT WITH ANYTHING

10

Primary hyperparathyroidism what are the lyte findings

hypersecretion of parathyroid hormone,

which acts to

increase the serum level of calcium.

Secondary effects of this hormone are a

decrease in serum phosphate levels due to poor renal reabsorption,

elevated urinary calcium levels.

increased chloride

11

surgical and Adjuvant for parathyroid cancer

en bloc resection with an ipsilateral thyroidectomy.

radiation post op has been shown to decrease local recurrence.

NO role for chemotherapy for these tumors

12

high grade versus low grade MALToma

Low grade lymphomas can be precipitated by an H.pylori infection and can be treated with antibiotics alone, which usually include Clarithromycin and Amoxicillin. Even with surrounding nodes are seen to be positive on CT

High grade lymphomas are better treated with a combination of chemotherapy and radiation. CHOP. Radiation is also used to treat high grade lymphoma.

Surgery is rarely indicated with gastric lymphoma and is only reserved for instances of perforation or uncontrolled bleeding.

13

If the results from the thyroid FNA are inconclusive, then the recommendation is

either repeat the procedure

or

have close follow up within three months

The majority of nodules with indeterminant FNA samples ultimately are found to be benign.


Surgery is not indicated after one failed attempt of FNA for diagnosis

14

percent of renal artery stenosis required for hypertension to occur

Renovascular hypertension is most commonly due to atherosclerosis of the renal artery, where
approximately 60% of the vessel needs to be occluded before hypertension will occur

15

where is the mean arterial pressure sensed in what is result when there is renal artery stenosis

A decrease in the mean arterial pressure is sensed by baroreceptors in the afferent arteriole which lead to stimulation of the juxtaglomerular apparatus, and ultimately activation of the renin-angiotensin axis

The overproduction of renin leads to hypertension that is difficult to manage with medications.

Patients may benefit from percutaneous transluminal angioplasty to decrease the renal artery stenosis.

16

The most common malignant tumor of the parotid gland is


mucoepidermoid carcinoma,

histologically consists of epidermoid and mucous cells.

low-, intermediate-, or high-grade, directly
related to the proportion of epidermoid to mucoid cells found on histologic examination.

17

tx of
mucoepidermoid carcinoma

treated with total parotidectomy, radical neck dissection and postoperative radiotherapy, regardless of nodal status!

CAREFUL, this is exception - as most neck disections are triggered by nodal status!!



High-grade mucoepidermoid carcinomas are highly aggressive, with a local recurrence rate of 60%, regional metastatic rate of 50%, and distant metastatic rate of 30%. These tumors are

with a 5-year survival of 50%.


18

Tx of far-advanced parotid gland carcinoma

prepared for an
extended, radical parotidectomy,
which may involve resection of overlying skin, adjacent mandible and soft tissue, temporal bone, and a portion of the adjacent external ear.

With advanced presentations, the facial nerve is invariably sacrificed in these patients; free tissue transfer may be necessary for repair.

19

The most common malignancy of the submandibular gland

adenoid cystic carcinoma

This is also the second most common of the parotid gland

propensity for perineural invasion and spread, as well as distant metastases

20

Tx of adenoid cystic carcinoma

Surgical management of these tumors
The most common malignancy of the submandibular gland (and the second most common of the parotid gland)


includes radical resection,
sacrificing nerves only for direct tumor extension

and

postoperative radiation therapy.

Despite this aggressive therapy, these tumors, which follow an indolent course, develop regional and distant metastases 40% of the time over a 10- to 20-year course.

21

Gross and histo features of pleomorphic adenoma

The most common benign lesion of the major salivary glands


Grossly,
smooth and lobular,
well-defined capsule.

Histologically, however,
epithelial and mesenchymal components

incomplete encapsulation

with pseudopod extension beyond the apparent borders of the mass.

These features account for the high recurrence rate when tumors are removed by enucleation alone.

22

tx of pleomorphic adenoma

resection of the tumor

WITH a margin of normal gland surrounding it.

The intimate relationship between the parotid gland and the facial nerve necessitates facial nerve identification and dissection to ensure its preservation and complete tumor extirpation.

23

Warthin's tumors characteristics and treatment

are typically BENIGN (even though 10% bilateral!!)

cystic lesions

tail of the parotid gland.

often multicentric,

approximately 10% are bilateral

Treatment

superficial parotidectomy, similar to pleomorphic adenoma.

24

treatment of Squamous cell cancer of the parotid lobe is

another indication for a neck dissection even with clinical neg nodes!

25

Percent gastrinomas malig

Although slow growing, more than 60% of gastrinomas are malignant

26

sporatdic vs familial gastrinoma percentages

sporadic (80% of cases)

familial or inherited (20% of cases)

27

Male to female gastinoma ratio


There is a male preponderance, with a male-to-female ratio of approximately 2:1

28

Symptoms of adrenal insufficiency



reflect glucocorticoid AND mineralocorticoid deficiencies.

fever,
nausea, vomiting,
refractory hypotension,
lethargy.

Acute adrenal insufficiency is a medical emergency and should be suspected in stressed patients with a history of either adrenal insufficiency or exogenous steroid use.

29

hypercalcemic crisis ssx

Muscle weakness, fatigue, coma, and hypercalcemia are seen in patients with


30

thyrotoxicosis crisis (thyroid storm ssx

Fever, tachycardia, irritability, vomiting, and diarrhea (and diarrhea)

31

Laboratory findings of adrenal insufficiency include

hyponatremia,
hyperkalemia,
azotemia,
fasting or reactive hypoglycemia.

Hypercalcemia may also be present.

32

best test for both acute and chronic adrenal insufficiency

The rapid ACTH stimulation
(also called the cosyntropin stim test)

Synthetic ACTH (250 !g) is administered intravenously, and plasma cortisol levels are measured 30 and 60 minutes later.

Normal peak cortisol response should exceed 20 !g/dL.


33

the best test to establish primary hyperaldosteronism

Demonstration of an elevated plasma aldosterone concentration in the setting of suppressed plasma renin is

34

Cholecystokinin stimulates

contraction of the gallbladder

and

secretion of:

bicarbonate
secretin

CCK also stims release of pancreatic enzymes!


35

Pancreatic Polypeptide is known to

suppress bile secretion,
gallbladder contraction,
exocrine pancreatic function.

36

Acetylcholine effect on gastric acid and bicarb secresion

triggers the release of gastric acid

and

bicarbonate secretions.

37

Somatostatin is an inhibitory peptide found both in

hypothalamus

and

pancreatic delta cells

38

Pheochromocytomas can be localized using

Iodine-131 methyliodobenzylguanidine (I-131 MIBG) scan.

I-131 MIBG is preferentially taken up by the adrenal medulla and chromaffin tissue.

Pheochromocytomas are localized to the site of activity.

39

Gastrin stimulates

gastric acid secretion

pepsinogen secretion.

It also stimulates gastric mucosal growth.

40

Gastrin is released from

Gastrin is released from the G cells in BOTH the

antrum

and

duodenum

(CAREFUL - even thought you wouldn't think you would want acid secreted in your small bowel - the duodenum can handle it because it has the brunner glands

41

The release of gastrin is stimulated by

food components contained within a meal,

especially protein digestion products

antral distention,

gastrin- releasing peptide

vagal stim

and

adrenergic stimulation (this is why you have heartburn when you are nervous)



42

Prolonged hypergastrinemia from any cause leads to

mucosal hyperplasia

increase in the number of enterochromaffin-like cells

Under some circumstances, gastrin is associated with the development of gastric carcinoid tumors (but NOT MALTomas)

CARFUL - H pylori is associated with MALToma (and H pylori also is assoicated with hypergastronemia)

43

Anaplastic thyroid carcinomas

are one of the most aggressive malignancies, with few patients surviving 6 months beyond initial presentation. These tumors affect patients 60-70 years old. Women are more commonly affected than men, with a ratio of 3:2. Typically, patients have a long-standing neck mass that enlarges rapidly. This sudden change is often accompanied by pain, dysphonia, dysphagia and dyspnea. Often the mass is quite large and fixed to the tracheolaryngeal framework, resulting in vocal cord paralysis and tracheal compression. More than 80% have jugular lymph node involvement at the time of presentation and greater than 50% systemic metastases. Most patients die of superior vena cava syndrome, asphyxiation or exsanguination.
Answers A & B & C & D: The aggressive nature of this tumor is not characteristic of these types of thyroid carcinoma.

44

Bilateral adrenalectomy is the treatment of choice for

bilateral adrenal hyperplasia causing Cushing’s syndrome.

It can also be considered in cases where pituitary surgery has failed.



Choice C: Primary adrenal Cushing’s syndrome can be treated with adrenalectomy and has a 90% success rate.
Choice D: Pituitary microsurgery has a 75% success rate for cure of Cushing’s syndrome caused by pituitary adenoma in experienced hands.
Choice E: When initial surgical intervention for pituitary Cushing’s has failed, reoperation or pituitary radiation may improve remission rates.

45

treatment of bilateral adrenal hyperplasia with or without clinical cushings

In patients with BMAH in whom aberrant hormone receptors are not present or for which no specific pharmacological blockade is available or effective:

•We suggest bilateral adrenalectomy for severe Cushing's syndrome with urinary free cortisol (UFC) >2 times the upper limit of normal (Grade 1B). (See 'Surgery' above.)

•We suggest unilateral adrenalectomy in patients with moderately increased cortisol production (less than twofold increase in UFC levels) and clinical evidence of cortisol excess (Grade 2C). (See 'Surgery' above.)

•In patients with subclinical BMAH and normal levels of urinary cortisol, the decision between observation and surgery should be based on clinical evidence of cortisol excess (hypertension, diabetes, osteoporosis, or neuropsychological manifestations).

46

SIADH should be suspected with what findings

in any patient with hyponatremia, hypoosmolality, and a urine osmolality above 100 mosmol/kg. In SIADH, the urine sodium concentration is usually above 40 meq/L, the serum potassium concentration is normal, there is no acid-base disturbance, and the serum uric acid concentration is frequently low.

ADH secretion results in a concentrated urine and therefore a reduced urine volume

In most patients with SIADH, ingestion of water does not adequately suppress ADH, and the urine remains concentrated. This leads to water retention, which increases total body water (TBW). This increase in TBW lowers the plasma sodium concentration by dilution. In addition, the increase in TBW transiently expands the extracellular fluid volume and thereby triggers increased urinary sodium excretion, which both returns the extracellular fluid volume toward normal and further lowers the plasma sodium concentration.

47

Conn’s syndrome

PRIMARY hyperaldosteronism,
30 to 50 years

Aldosterone up
HYPER Na

Renin down
HYPO K

HYPERtension


autonomous secretion of aldosterone

causes Hypertension which supresses renin secretion by the feedback

Due to the lack of autoregulatory inhibition by renin, aldosterone secretion causes sodium retention and potassium wasting.


48

hypokalemia symptoms

fatigue,
muscle weakness,
polydipsia,
polyuria,
nocturia,
headaches.

49

Addison disease is characterized by


hypotension

decreased cortisol

decreased aldosterone levels.

hyponatremia and hyperkalemia - OPOSITE of Conns

50

medullary carcinoma cell origin and embryo


The ventral portion of the 4th pharyngeal pouch develops into the ultimobranchial bodies early in the development of the thyroid gland.

These structures contain neural crest cells

fuse with the thyroid and lead to the formation of the parafollicular cells.

Calcitonin is the product of these “C cells”.

Medullary thyroid carcinoma is a neuroendocrine neoplasm derived from the parafollicular cells and calcitonin, therefore, can be used as a surveillance marker for recurrence following resection.

51

he most useful and widely used biochemical test for diagnosing carcinoid tumors in the symptomatic patient

24-hour urine 5-HIAA measurement with a sensitivity and specificity of 73 and 100%,

5-HIAA is excreted in the urine after serotonin metabolism and is measured more reliably than serotonin levels, which can vary between persons.

Platelet serotonin levels may be more sensitive than urine or blood tests but is not readily available at many institutions.

52

Somatostatin receptor scintigraphy scan - when is it used

considered after the diagnosis of carcinoid has been confirmed

to identify occult metastasis in patients being considered for curative resection

and

to determine if the patient is likely to respond to octreotide.

53

After undergoing a total thyroidectomy, patients should receive

radioactive iodine treatment to ablate the remnant thyroid bed to decrease the likelihood of recurrent disease.

Radioablation also allows the physician to subsequently follow thyroglobulin levels as a marker for thyroid cancer activity.

Patients who do not undergo radioablative therapy carry a two-fold increased mortality rate at 10 years compared with patients who receive radioablation.


54

what is surv to assess for recurrence follicular thyroid cancer

Following thyroglobulin levels is used postoperatively to assess for recurrence, NOT repeat ultrasounds.

55

asymptomatic multinodular goiter managment

has the possibility to progress to a toxic multinodular goiter if it becomes autonomously functioning, therefore treatment is warranted.

The first step is to confirm the nodules are not malignant - FNA

iodine supplements (WATCH OUT possibility of precipitating thyrotoxicosis)

Up to 80% of patients with iodine deficiency goiter will see a decrease in the size of the goiter with levothyroxine treatment

If the nodules continue to increase in size, or are too numerous to adequately sample by fine needle aspiration (FNA), a thyroidectomy may be indicated

Radioactive iodine treatment (RAI) treatment is used to treat Graves’ Disease

56

Congenital adrenal hyperplasia can be diagnosed by checking levels of what; and what are presentation and lab findings

INCREASED 17-OH progesterone

due to lack of an enzyme that is involved in the production of cortisol.

increased levels of 17-OH progesterone causes:

decreased cortisol levels

salt wasting which can elicit

hypotension.

Bottom Line: The most common form of CAH is 21-hydroxylase deficiency which causes salt wasting.

57

Calcitonin is released from

parafollicular cells of the THYROID (these are associated with medullary thyroid)

oppose PTH

stimulated by high levels of calcium

inhibits osteoclastic activity

A secondary action of calcitonin is increased phosphorus excretion in the kidney

High levels of calcitonin can be seen in medullary thyroid cancer

58

The cervical esophagus derives its blood supply from the

inferior thyroid artery

59

The inferior thyroid artery is a branch of the

thyrocervical trunk which is a branch of the subclavian artery.

60

What test is used to determine whether Cushing’s syndrome associated with elevated ACTH levels are caused by a pituitary adenoma or an ectopic source of ACTH production.

A high dose dexamethasone suppression test

The test is performed by administering 2 mg of dexamethasone every 6 hours for 48 hours. An elevated cortisol level after this study is diagnostic of an ectopic source of ACTH production. If there is a pituitary adenoma, the cortisol level should be suppressed after dexamethasone administration.

61

The first step in determining the diagnosis of primary hyperaldosteronism is

calculating the ratio of plasma aldosterone to plasma renin activity

cutoff value of 30 will provide a sensitivity of approximately 90%.

An absolute aldosterone concentration of 15 mg/dL will increase the specificity of screening and should be measured.

A 24 hour urine aldosterone level is measured after salt loading with either iv saline over 6 hours or oral salt loading over a 3 day period.

A positive test will demonstrate higher than normal levels of aldosterone in the urine.

The preferred initial test for localization is a thin cut (3 mm) CT scan

Adrenal vein sampling only if can not find adrenal adenoma if CT scan

This test in not necessary in patients younger than 40 years old with symptoms of hyperaldosteronism when a solitary adrenal mass greater than 1 cm is found on CT and a normal contralateral gland is seen.

When these conditions are met, surgical intervention is recommended without further studies.

Adrenal vein sampling is performed by measuring the aldosterone and cortisol levels in the peripheral circulation as well as the left and right adrenal veins. A ratio of aldosterone to cortisol fourfold higher on one side compared

62

Cushing syndrome present with

weight gain, muscle weakness, bone pain, and high blood pressure.

63

Functional adenocarcinoma present with

rapidly progressive Cushing syndrome
or
mixed presentations with signs of both Cushing syndrome and virilization.

64

Women with postnatal congenital adrenal hyperplasia due to 21 hydroxlase enzyme deficiency typically present with

virilization and hirsutism,
polycystic ovaries,
and
irregular menses.

AND have features of hypocortisolism and hypoaldosteronism.

65

Patients with hyperaldosteronism typically present with

hypokalemia, muscle weakness, and hypertension.

66

According to the TNM staging system of adrenocortical carcinoma what is T2

tumor size is > 5 cm

ANd if no fat invasion (T3), lymph nodes involvement, or distant metastasis = stage 2 for T2

67

adrenocortical carcinoma Stage I

Stage I is T1N0M0.
According to the TNM staging T1 is a tumor less than 5 cm with no invasion.

68

adrenocortical carcinoma Stage III

either T1-2, N1, M0

or

T3N0M0.

T3 is a tumor with inavsion to the fat.

This patient has neither lymph nodes involvement nor periadrenal fat invasion.

69

adrenocortical carcinoma Stage IV

Stage IV is either any T, any N, M1

or

T3- 4N1M0.

T4 is a tumor with organ invasion

70

indications for total thyroidectomy besides cancer

Grave's disease and severe ophthalmopathy

Severe thyrotoxicosis, resistant to medical management

Multinodular goiter

71

treatment of Lymphoma of the thyroid

chemo and possible also xrt

72


Somatostatin is released from

D cells located in the antrum

73

stimulation for Somatostatin releas

response to an acidic environment

74

actions of Somatostatin

inhibition of gastrin
inhibition bicarbonate secretion

These actions are generated by paracrine effects on parietal and G cells

75

GIST location with best prognosis

primary gastric gastrointestinal stromal tumors (GIST) seeming to fare better than those of small bowel or rectal origin.

76

The most common locations for GIST

stomach (60% to 70%),
small bowel (20% to 25%),
colorectum (5%)
esophagus (5%).

77

Biopsy of GIST

NO Percutaneous core or intraoperative biopsy of a suspected GIST that is localized and presumed to be resectable

-tumors tend to be
soft, well vascularized, and friable, and tumor spill or spontaneous rupture portends a poor prognosis and compounds the difficulty of treatment decisions.

YES endoscopic biopsy is relatively safe either by direct visualization of a mucosal component or by endoscopic ultrasound guidance.

78

MEN 2B individuals develop


MTC,
pheochromocytomas,
megacolon,
ganglioneuromatosis,
characteristic physical appearance,
hypergnathism of the midface,
marfanoid body habitus,
multiple mucosal neuromas.

79

After a partial thyroidectomy for papillary thyroid carcinoma, patients are followed with what management

thyroid hormone to suppress TSH

closely followed with ultrasonography.

NO thyroglobulin levels because this is only used after total as a bionary marker of absent or present - it should remain undetectable after total

80

Primary hyperaldosteronism findings

Conn’s syndrome,

High serum Na
low serum K+,

high urinary K+,
low urinary Na+,

metabolic alkalosis (dumped hydrogen for sodium)

medically refractory hypertension

elevated aldosterone levels.

Due to the lack of autoregulation by renin, a plasma aldosterone to renin ratio greater than 25 is highly suggestive of the
diagnosis. (this means that renin is relatively low compared to aldosterone)

increasing sodium retention (from incr aldo) in exchange for hydrogen in the cortical collecting tubules and potassium in the gut, salivary, and sweat glands.


81

determine whether a pheochromocytoma is malignant.

There are no reliable histopathologic criteria

Pheochromocytomas are defined as malignant when there are tumor implants distant from the primary mass in NON neuroectodermal tissue:

The axial skeleton,
lymph nodes
liver,
lung,
kidney (careful, kidney involvement considered metastatic or considered distant..)

are the most common sites of metastasis.